Spitzer update on DSM-V transparency

The latest on the controversy

Robert Spitzer, MD, chair of the DSM-III and DSM-III-R workgroups, has issued an update on efforts to reduce the secrecy surrounding the American Psychiatric Association's DSM-V revision process:

"As those of you who have followed this issue know, APA leadership has been resistant to improving the transparency of the revision process. At the outset, all DSM-V Task Force and Workgroup members were required to sign a confidentiality agreement that prohibited them from discussing anything about the DSM-V revision process.... Requests to APA leadership to see minutes of Task Force and Workgroup meetings were refused on the grounds that releasing minutes would compromise the revision process by inhibiting free discussions among Workgroup members. It also was argued that making minutes of meetings and conference calls would jeopardize APA's intellectual property rights. How this would happen has never been explained....

"Pressure on APA leadership to increase transparency culminated in the drafting of an Action Paper by some members of the APA Assembly. The paper called for the posting of the minutes to the DSM-V workgroup and task force meetings on the DSM-V web site....

"Although clearly a move in the right direction, I believe that these reports fall far short of providing the requisite transparency. The Workgroup reports are quite variable in terms of the amount of detail they provide regarding possible directions for change in the DSM-V....

"Full transparency of the process will only be satisfied by posting the minutes of all DSM-V conference calls and meetings so that the process of the deliberations is evident to all . Anything less is an invitation to critics of psychiatric diagnosis to raise questions about the scientific credibility of DSM-V. That is exactly what Christopher Lane, a harsh critic of the DSMs, did in an Op-Ed piece for the LA Times.

"One of the oft-repeated DSM-V talking points is that the process is 'open and transparent.' To be truly transparent, the nuts and bolts of the DSM-V process needs to be open for outside scrutiny. When it comes to the crucial issue of transparency, even the appearance of impropriety must be avoided. Rather than appearing open and transparent, current APA policy continues to give the appearance that APA has something to hide about how it is developing DSM-V. It remains likely that unwanted media attention will fall on the DSM process until full transparency is achieved."

The only Task Force report posted so far is here. Progress reports from the individual workgroups are posted here.

My readers will be especially interested in the report from the Sexual and Gender Identity Disorders workgroup, which will make recommendations for the highly controversial Paraphilias section of the DSM. The brief report is very vague and really doesn't say much. Rumor has it that the workgroup may be considering adding a new diagnosis for nonsadistic rapists, a highly controversial proposal that was rejected the last time around but would help government experts at civil commitment proceedings. With the continuing secrecy surrounding the process there is no way to know for sure what the workgroup is up to; we'll just have to stay tuned.

Robert Spitzer can be reached via email at Spitzer8@verizon.net.

More on the DSM-V controversy

"The new mental disorders?"

Inspired by last week's op-ed in the L.A. Times, Atlanta Journal-Constitution staff writer Richard Halickshas has a new piece questioning some of the strange new diagnoses being proposed for the DSM-V:

Sex addiction. Internet addiction. Compulsive buying disorder. All of these and more could become officially recognized mental disorders in the next few years. The American Psychiatric Association is creating the fifth edition of its Diagnostic and Statistical Manual, or DSM-V, which defines mental disorders and adds new ones with each edition.

Christopher Lane, author of the book "Shyness: How Normal Behavior Became an Illness," complained last week that the new DSM, due out in 2011, is being put together in secret, a charge that DSM's editors denied.

In "Wrangling Over Psychiatry’s Bible," published in the Los Angeles Times, Lane also warned that the creation of new disorders where none currently exists may be "little more than a pretext for prescribing profitable drugs."

Here's a look at selected new ailments under consideration by the committees of experts writing DSM-V.

Sex addiction

Real, says Dr. Patrick Carnes, a leading researcher in the field. It's a "compulsive behavior that completely dominates the addict's life. Sex becomes the organizing principle of addicts' lives."

Not real, says Seattle therapist Roger Libby. Slate.com quotes Libby: "You cannot be addicted to yourself. You have to have a substance external to yourself like alcohol or drugs to be addicted."

Caffeine withdrawal disorder

Real, say Johns Hopkins University researchers. Withdrawing from the world's most-used drug causes headache, fatigue, irritability, depression, difficulty concentrating, even flulike symptoms.

Not real? Few seem to argue against this. It's in DSM-IV as a trial diagnosis and is up for official diagnosis designation in DSM-V.

Parental Alienation Syndrome

Real, says paskids.com: [PAS] "arises primarily in the context of child-custody disputes. Its primary manifestation is the child’s campaign of denigration against a parent, a campaign that has no justification."

Not real, says the National Organization for Women: "Parental alienation really is a dangerous and cleverly marketed legal strategy that has caused much harm to victims of abuse, especially women and children during and post-divorce."

Internet addiction

Real, says Dr. Jerald Block, writing in the American Journal of Psychiatry: "Internet addiction appears to be a common disorder that merits inclusion in DSM-V… . [It] consists of at least three subtypes: excessive gaming, sexual preoccupations and email/text messaging."

Not real, argues thelastpsychiatrist.com. "Internet addiction belongs in DSM-V… . And then let's rename the DSM The Book of Fantastikal Magickal Pixies and incorporate it into the Monster Manual."

As you see in the above coverage, the APA denies the charge by Lane and others, including none other than DSM-III Task Force Chairman Robert Spitzer, that the DSM-V revision process is occurring in secrecy.

But, as Spitzer points out in a letter to Psychiatric News, the secrecy is spelled out quite clearly in the contract that all DSM-V task force members must sign:

"I will not, during the term of this appointment or after, divulge, furnish, or make accessible to anyone or use in any way... any Confidential Information. I understand that 'Confidential Information' includes all Work Product, unpublished manuscripts and drafts and other pre-publication materials, group discussions, internal correspondence, information about the development process and any other written or unwritten information, in any form, that emanates from or relates to my work with the APA task force or work group."

The Atlanta Journal-Constitution article is online here. Spitzer's letter about the secrecy is here. My previous post on the DSM makeover controversy is here.

Hebephilia struck by third blow

Down but not out?

It may be too soon to call it the death knell, but this week's ruling by a federal judge in Massachusetts certainly dealt a reeling blow to the highly contested pseudo-diagnosis of hebephilia and its ever-more-marginalized adherents.

In the third of three back-to-back decisions in federal court, U.S. District Judge Joseph Tauro said hebephilia just doesn't pass muster as a basis for civilly committing someone as a "sexually dangerous offender."

Hebephilia -- sexual attraction to adolescents -- certainly exists in nature, but the Government failed to meet is burden of establishing by clear and convincing evidence that it amounted to "a serious mental illness, abnormality, or disorder" as required for civil commitment, wrote the judge. Simply put, "hebephilia is not generally recognized as a serious mental illness by the psychological and psychiatric communities."

The case involved Todd Carta, who was due to be released from federal prison after serving time for computer-based child pornography. Carta has a lengthy history of sex with underage males, ages 13 on up, and has acknowledged an attraction to adolescent boys.

The Government's expert, psychologist Amy Phenix, diagnosed Carta with "Paraphilia Not Otherwise Specified: Hebephilia," which she defined as a sexual preference for "young teens . . . 'till about age seventeen."

Phenix's position was countered by psychologist Leonard Bard, who testified that Carta had no diagnosable mental disorder. Bard identified numerous problems with the diagnosis of hebephilia, including its absence from the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the prevalence of sexual attraction to adolescents among normal men.

The judge got it. In a thorough and well reasoned decision, he deconstructed the legal use of this nebulous diagnosis brick by brick. Perhaps most impressive was his clearly articulated understanding of the importance of adequate empirical research to support a diagnosis:

"Most importantly, the Government has failed to demonstrate that a diagnosis of hebephilia or paraphilia NOS: hebephilia is supported by research in the field of psychology…. Most of the articles put forward by the Government were published by coauthors Dr. Blanchard and Dr. Cantor. Dr. Bard criticized the work of Dr. Blanchard and Dr. Cantor, testifying that they are both on the editorial board of the journal that publishes their findings, which has at least the potential to damage the integrity of the peer-review process. Dr. Bard also criticized the research underlying their conclusions for failing to include a control group and for eliminating a large portion of the samples, among other problems. The five replies criticizing Dr. Blanchard's recent article proposing inclusion of hebephilia in the DSM-V suggest that Dr. Blanchard's work is not widely accepted. Dr. Bard testified that 'it’s the same group that is published over and over again trying to justify [a diagnosis of hebephilia], and they have failed.' "

The judge acknowledged that by ordering Carta's release he was not suggesting the convicted sex offender is a model citizen, but just drawing a line in the sand between criminality and mental disorder: Absent a widely recognized mental disorder it is Unconstitutional to "order indefinite commitment on the basis of the offensiveness of Respondent's conduct alone."

This is the third federal ruling in a row against hebephilia. The only other federal courts to address its use both rejected it as a basis for civil commitment. Those cases were U.S. v. Shields and U.S. v. Abregana, both decided last year.

Normally, this might be a "Three Strikes and You're Out" situation. Put the tired old construct to bed.

But fans are frantically trying to rehabilitate and rejuvenate hebephilia by getting it added to the next edition of the DSM (DSM-V). This would get around at least one of the many concerns expressed by Judge Tauro and others, over "the lack of any clear criteria" for making the diagnosis. Spearheading the DSM-V effort is Raymond Blanchard of the Centre for Addiction and Mental Health in Canada, who not only sits on the editorial board of the journal that published his research (as Judge Tauro pointed out in his opinion), but also serves on the DSM-V Sexual and Gender Identity Disorders Work Group. From that influential position, he is lobbying for the addition of hebephilia or a newly minted term – pedohebephilic disorder (what a mouthful!) to the diagnostic bible.

With the DSM-V work groups stacked (see my related posts HERE), we may just have to wait and see. But in the meantime, All Hail to Massachusetts, for landing a solid blow against pseudoscience in the forensic arena.

Judge Tauro's decision is HERE. A list of articles on "Hebephilia and the DSM-V Controversy" is HERE; for more on hebephilia see my essay, "Invasion of the hebephile hunters: Or, the story of how an archaic word got a new lease on life."

Photo credit: Noel Kerns' "Closed," Creative Commons license (entrance to the defunct Mission Four Outdoor Theatre in San Antonio, Texas)

DSM-V: Urgent warning and call to action

Predicting a flawed manual that "will haunt psychiatry for many years to come," the chair of the DSM-IV Task Force has issued an urgent call to the American Psychiatric Association to change course on its revision process for the Diagnostic and Statistical Manual of Mental Disorders (DSM) before it is too late.

Allen Frances' strongly worded appeal in the Psychiatric Times predicts the DSM-V -- scheduled for publication in May 2012 - will usher in a flood of new mental disorders that will medicalize normality, producing "a bonanza for the pharmaceutical industry but at a huge cost to the new false-positive patients caught in the excessively wide DSM-V net."

"In my experience, experts on any given diagnosis always worry a great deal about missed cases but rarely consider the risks of creating a large pool of false positives—especially in primary care settings. The experts' motives are pure, but their awareness of risks is often naive. Psychiatry should not be in the business of inadvertently manufacturing mental disorders."

Frances makes special note of the potential for "unpredictable and consequential" unintended consequences in forensic settings:

"Years after the DSM-IV was completed, we learned about the enormous unintended impact of a seemingly slight wording change we made only for technical reasons in the section on paraphilias. A misreading of our intentions in making the change had led to great confusion -- with forensic evaluators using the diagnosis of paraphilia not otherwise specified to justify the sometimes inappropriate lifetime psychiatric commitment of rapists who had no real mental disorder."

This prediction is prophetic in light of current lobbying efforts by the paraphilias subworkgroup to create a new "pedohebephilic disorder" category that could vastly expand sex offender diagnosis, proving a bonanza for the sexual offender civil commitment industry.

Frances is highly critical of the "inexplicable secrecy and the lack of openness to outside influence and criticism" surrounding the DSM-V revision process.

"Restricting the free flow of ideas creates enormous blind spots that greatly increase the risk of damaging unintended consequences…. The advisory group is far too small and select to reduce, rather than encourage, heated debate. In producing a new edition of the DSM, your harshest critics eventually turn out to be your best friends because they are most likely to help you avoid pitfalls."

He is urging the American Psychiatric Association to create an external committee to review what is going on with the DSM and make recommendations to avoid serious negative consequences in the future.

Frances' important article, A Warning Sign on the Road to DSM-V: Beware of Its Unintended Consequences, is available HERE.

An accompanying Q&A, DSM-V Badly Off Track, is HERE.

Some of my related blog posts are HERE.

DSM-V: Will shoddy manual implode years before launch date?

The DSM-V debacle continues to expand like a mushroom cloud following a nuclear explosion. Media pundits right and left are commenting critically on the draft manual, published online after years of cloak-and-dagger secrecy.

As most of you know by now, the American Psychiatric Association has granted the public a very brief window in which to comment online on the draft proposals. I haven't seen an explanation of how public input will be tallied or used. Will a popularity contest influence psychiatric diagnosis? We've seen how well citizen input works here in California, where the initiative process has brought government to a standstill. Can you imagine neurologists setting up a website to get lay input on a new diagnostic scheme for brain tumors? This debacle only underscores the point that the DSM is more politics than science.

Among the best commentaries I've seen this week are Sally Satel's op-ed in the Wall Street Journal and Allen Frances' piece in Psychiatric Times. Science magazine also has an interesting analysis of the proposed behavioral disorders, which would medicalize harmful habits like gambling, overeating, and down the line perhaps "Internet Addiction." All three articles touched on the negative forensic consequences of the radical proposed changes.

"Prescriptions for Psychiatric Trouble"

Psychiatrist Sally Satel, a resident scholar at the American Enterprise Institute, lecturer at Yale University School of Medicine, and a brilliant thinker, critiqued psychiatry's endless drive to expand mental disorder, placing ever-larger "swaths of the population under the umbrella of pathology." As Satel points out, the DSM-V continues the troubling tradition, launched 30 years ago with publication of the manual's third edition, of elevating reliability over validity:

[J]ust because two examiners concur that a person qualifies for a particular diagnosis does not mean that he has an authentic mental illness. How do we know, for example, that a person diagnosed with major depressive disorder (the formal designation for pathological depression) is not actually suffering from a bout of natural if intense sadness brought on by a shattering loss, a grave disappointment or a scathing betrayal?

The manual will not help us here. In fact, a number of changes proposed for the DSM V (e.g., new diagnoses for binge eating, hoarding and hypersexuality) are likely to inadvertently place large swaths of normal human variation under the umbrella of pathology.

Both she and Allen Frances, former chair of both the DSM-IV Task Force and of the department of psychiatry at Duke University School of Medicine, believe that Psychosis Risk Syndrome may be the scariest example of overinclusion. Hundreds of thousands of young people, especially the poor and minorities, could be given this highly stigmatizing label and medicated with extremely dangerous drugs, even though these medications are not very effective and the broad majority of these youngsters would not go on to develop psychoses if left alone.

In his critique in Psychiatric Times, aptly titled "Opening Pandora's Box," Frances notes that the DSM-V "would create tens of millions of newly misidentified false positive 'patients.' " Not only could almost anyone qualify for at least one of the new diagnoses (which include such nebulous constructs as Mixed Anxiety Depressive Disorder, Minor Neurocognitive Disorder, Temper Dysfunctional Disorder with Dysphoria, and -- in a big nod to America's 12-Step religion -- Addiction Disorder), but thresholds are being lowered for many existing disorders as well.

Forensic applications: Disastrous unintended consequences

One of the DSM-V developers' most troubling weaknesses is their profound "insensitivity to possible misuse in forensic settings," Frances notes. As an example, he cites Pedohebephilia, "one of the most poorly written and unworkable" proposals in the draft:

Expanding the definition of pedophilia to include pubescent teenagers would medicalize criminal behavior and further the previously described misuse of psychiatry by the legal system. Certainly, sex with under-age victims should be discouraged as an important matter of public policy, but this should be accomplished by legal statute and appropriate sentencing, not by mental disorder fiat.

Two other potential "forensic disaster[s]" are Hypersexuality Disorder and Paraphilic Coercive Disorder, both of which will be used to expand the pool of sex offenders eligible for indefinite civil commitment on the basis of purported mental disorder.

In Frances' opinion, based on having worked on the three previous editions of the DSM and knowing many of the drafters of the current version, critics are missing the mark by focusing on alleged financial and/or professional conflicts of interest. Rather, the DSM-V work group members are sincere and well meaning, but have a natural, "and seemingly irresistible," tendency to expand the boundaries of diagnoses in order to identify and treat all potential sufferers. This "diagnostic imperialism" produces a fatal blind spot:

Unfortunately, Work Group members … [miss] the fact that every effort to reduce the rate of false negatives must inevitably raise the rate of false positives (often dramatically and with dire consequences). It is inherently difficult for experts, with their highly selected research and clinical experiences, to appreciate fully just how poorly their research findings may generalize to everyday practice -- especially as it is conducted by harried primary care clinicians in an environment heavily influenced by drug company marketing…. [T]he DSM5 suggestions display the peculiarly dangerous combination of nonspecific and inaccurate diagnosis leading to unproven and potentially quite harmful treatments.

Frances strongly argues that the time to weed out implausible and even "incoherent" proposals is now, not after the proposed field testing:

I feel it is my responsibility to raise clear alarms now because the past performance of the DSM5 leadership does not inspire confidence in its future ability to avoid serious mistakes.... Field trials are arduous and expensive and make sense only for testing the precise wording of criteria sets that have a real chance of making it into the manual -- not for the many poorly written and far out suggestions that have just been posted. It seems prudent to identify and root out problems now lest they sneak through in what will likely be an eventual mad rush to complete DSM5....

Because of the secretive and closed nature of the DSM5 process, the expectable enthusiasms of the experts who comprise the Work Groups have not been balanced, as they must always be, with real world practical clinical wisdom and a careful risk/benefit analysis of the possible unintended consequences of every suggestion.

It would be reckless now to rely on the complacent assumption that all these problems will eventually come out in the wash. By its previous actions and inactions, the DSM5 leadership has sacrificed any "benefit of the doubt" faith that their process will be self-correcting in a way that guarantees the eventual elimination all of the harmful options.

Note: If you want to read Sally Satel's op-ed, do it now; after seven days, Wall Street Journal articles are only available by subscription. I highly recommend that forensic experts and attorneys carefully review Frances' article, and note his recommendation for greater forensic oversight. At minimum, if new diagnoses without established validity are included in the manual, the DSM should add a caveat that they are never to be used as grounds for civil commitment.

Special hat tip to the ever-helpful JANE

DSM-V: Get ready, get set . . . here it comes!

The American Psychiatric Association plans to launch its new DSM-V website tomorrow, February 10, publicly airing the long-anticipated diagnostic revision proposals and their criteria. I understand that two of the controversial forensic-related diagnoses I have blogged about extensively -- paraphilic coercive disorder and pedohebephilia -- are among those that made the draft manual.

Simultaneously, controversies grow on multiple fronts. On the one hand, we've got psychiatrists arguing that it's time to wrest the discipline back from all of those pesky non-psychiatrist interlopers. Writing over at the Psychiatric Times, Steven Moffic says the DSM-V should include an express clause saying only psychiatrists are qualified to use the manual.

Don't hold your breath. As long as psychiatrists keep charging many times the fees of other mental health practitioners, I guarantee that economic forces will keep Dr. Moffic's wish from coming true. Talk about trying to close the barn door after the horses are long gone!

Meanwhile, on the other side of the fence, the Association for Women in Psychology is saying, "Who wants it?" The Association has launched a new web site devoted to concerns about bias in the DSM-V diagnostic system. The site features a veritable link fest of criticisms, with articles on specific areas of diagnostic bias that will inordinately affect women, including anorexia nervosa, borderline personality disorder, female sexual dysfunction, and gender identity disorder.

Of particular relevance to forensic practitioners is an article critiquing parental alienation syndrome, proposed for the DSM-V, as well as articles on racism and social class bias in the diagnostic system.

Check it all out, folks. And if you disagree with anything you see, be sure to speak up now, before it's too late. The new manual, originally slated for publication in 2012, has been pushed back to May 2013, which may seem far away. But you only have two short months -- until April 20, 2010 -- to view the draft and make comments; after that, the website "will be available for viewing only." So much pseudoscience, so little time.

It's easy to register and make your comments. Whether the psychiatric gurus will listen is another story. But if you don't try, you'll never know.

Related resources:

Peter Aldhous, the award-winning science reporter covering the DSM debacle for New Scientist magazine, will be following up on his widely disseminated article, Psychiatry's Civil War, with a critical report on the latest developments. He is the guest on Michael Krasny's Forum on KQED radio on Wednesday (February 10); you can download the audio of "Updating Psychiatry's Bible" HERE.

DSM makeover: What will they come up with next?

Overhaul of diagnostic bible shrouded in secrecy

It's a tried-and-true formula:

1. Do a quick-and-dirty study or two.

2. Find a huge, perhaps escalating, problem that has heretofore been overlooked.

3. Create a product label (aka diagnosis).

And, voila! The drug companies will take it from there. A diagnosis that was once just a twinkle in the eye of a creative researcher becomes reified as a concrete entity.

Over the past couple of decades, the DSM has risen from its humble origin to an object of worship, regarded as the absolute scientific truth. Privately, however, many mental health professionals refer to it as a "joke." That's partly because we are aware of studies showing the poor validity of many of its constructs. It's also because we know about some of the forces (in addition to scientific progress) that influence each new edition. These include internal turf wars (the DSM-III was developed in large part to decrease the power of the psychoanalytic wing of psychiatry), cultural fads, group-think, and outside lobbying. And leading the outside lobbying, of course, is the pharmaceutical industry.

An example of how this process works is the case of shyness. Christopher Lane, an English professor and Guggenheim fellow, shows in his book, Shyness: How Normal Behavior Became a Sickness, how psychiatrists transformed shyness from a normal personality trait into a pathological condition labeled Social Anxiety Disorder. As Lane points out, not only can diagnoses be manufactured out of whole cloth, but their prevalence can be made to rise and fall like the stock market through arbitrary adjustments of the threshold cutoffs. And the DSM has a very low bar for calling something a disorder.

In writing his book, Lane was able to get unprecedented access to internal memos and letters of the American Psychiatric Association's DSM-III task force. Based on these primary sources, he credits the rise of the DSM from an obscure tract used mainly by state hospital hacks to an international bible to one man - Robert Spitzer - who chaired the task force and handpicked its members from people he considered "kindred spirits." (Spitzer is perhaps better known among the general public for his controversial stance that gay people could be turned heterosexual through reparative therapy.)

Over the years, the DSM has expanded from just 106 pages to its current 886. (See chart.) The severe mental disorders that once formed the book's core are still in there. There's just so much fluff that it's harder to find them.

And now, the American Psychiatric Association is at it again, working on the fifth edition that is set to launch in May 2012. But this time, perhaps in response to exposes such as Lane's, there will be no telltale memos and letters to document the process. Task force members are sworn to complete secrecy; they must sign a "confidentiality agreement" prohibiting them from disclosing anything to anyone.

Petition drive against secrecy

Ironically, even DSM-III architect Robert Spitzer is being excluded this time around. Denied access to task force committee minutes and other information, an angry Spitzer wrote a protest editorial that was rejected for publication by the American Journal of Psychiatry, the official journal of the American Psychiatric Association. (The editorial, "Developing DSM-V in Secret," is online here). With psychologist Scott Lilienfeld and others, Spitzer last month called for a petition drive to force the APA to open up the DSM-V revision process to public observation.

No doubt hoping to forestall such a petition drive, the APA just announced that its Assembly of local branch representatives will vote November 18 on an "action paper" that would encourage less secrecy. The vaguely worded paper calls on the APA's Board of Trustees to "develop policies and processes that balance the need for openness and transparency and the need to protect its intellectual property." If approved by the Assembly, the action paper will go before the association's Board of Trustees in December.

The secrecy issue comes amid mounting controversy over psychiatrists' ties to the drug industry. The U.S. Senate Finance Committee has launched an investigation into whether drug money is compromising the integrity of medical science. Prominent psychiatrist Charles Nemeroff of Emory University, whom critics have nicknamed "Dr. Bling Bling," is at the center of the probe; he reportedly earned millions of dollars from pharmaceutical companies while promoting drugs to heal depression and other emotional problems. (See Sunday's Atlanta Journal-Constitution.)

Perhaps all of this hubbub will encourage the DSM developers to be a bit more circumspect with new diagnoses, realizing that a massively overmedicated and increasingly cynical public could get fed up.

Perhaps the DSM's stranglehold on diagnosis would not be so serious if the book were only being used for its original and stated purpose, as a tool to help clinicians speak the same language in their efforts to understand and treat the mentally ill. But, increasingly, both medical and psychiatric disorders are being shaped by and for the pharmaceutical industry. (A good example of Big Pharma's influence over medical doctors is The rise of Viagra: How the little blue pill changed sex in America.) And in the forensic arena, the DSM is often employed pretextually, to accomplish various legal outcomes.

Proposed new diagnoses

So, what is in store this time around? Here's my sampling of some of the more controversial changes and new conditions being proposed, some with very specific relevance to forensic practice:

Parental Alienation Syndrome: This is by far the most controversial theory in high-conflict child custody litigation. And the battle lines are drawn primarily by gender: PAS is apt to be the first line of defense when a husband is accused in a custody battle of sexually abusing his children. Despite its lack of empirical support, a partisan lobby is pushing for its inclusion. (See my March 2008 blog post, "Showdown looming over controversial theory," for more background.)

Hebephilia: All psychodiagnoses, even those of psychotic disorders, have serious conceptual validity problems, but none are weaker than some of those being used to justify the civil commitment of sexually violent predators. The latest, and most farcical, is "hebephilia," or the sexual attraction to teens, which is being aggressively marketed by a small advocacy group. (I'll have more to say about this newly proposed diagnosis very soon; for now, you can check out my Halloween 2007 post, "Invasion of the hebephile hunters.")

Gender Identity Disorder: The proposed inclusion of this category has drawn the most fire, primarily from transgender activists, who have mounted a petition drive against Ken Zucker, chair of the sexual disorders task force. Information on this controversy can be found here, here, and here.

Among other novel constructs proposed for inclusion in the DSM-V are Internet Addiction and Relationship Disorder. If Big Pharma has its way, Female Sexual Dysfunction (FSD) could also be a contender (see my Amazon review of The Rise of Viagra). In addition, there are proposals to tweak the criteria for existing diagnoses relevant to forensic practice, including the sexual Paraphilias, Posttraumatic Stress Disorder, and Conduct Disorder.

For more information see:

Robert Spitzer’s documents criticizing the DSM-V secrecy (online here)

The APA’s official DSM-V website (here)

A critical analysis of psychodiagnosis more broadly (here)

My review of Christopher Lane's book, Shyness: How Normal Behavior Became a Sickness, is here. (As always, I encourage my readers and subscribers to click on the "yes" button if you find my Amazon reviews helpful; it helps get the word out.)

For further information on the pharmaceutical industry's role in the process, see my May 2008 blog post, "Who will write the next DSM?" and also check out my Amazon booklist, "Psychiatry and science: Critical perspectives."

Other academic articles on DSM diagnosis (not all of them available online, unfortunately) include:

Andreasen, N.C. (2007). DSM and the death of phenomenology in America: An example of unintended consequences. Schizophrenia Bulletin, 33, 108-112

Cunningham, M.D., & Reidy, T.J. (1998). Antisocial personality disorder and psychopathy: Diagnostic dilemmas in classifying patterns of antisocial behavior in sentencing evaluations. 16, 333-351.

Healy, D. Apr 15, 2006. The myth of 'mood stabilising' drugs. New Scientist (David Healy is a very controversial figure in this debate; Google his name for more on him)

Ruocco, A. (2005). Reevaluating the distinction between Axis I and Axis II disorders: The case of borderline personality disorder. Journal of Clinical Psychology, 61, 1509-1523

Stevens, G.F. (1993). Applying the Diagnosis Antisocial Personality to Imprisoned Offenders: Looking for Hay in a Haystack. Journal of Offender Rehabilitation, 19, 1-26

Tom Zander, Psy.D. (2005) Civil commitment without psychosis: The law's reliance on the weakest links in psychodiagnosis. Journal of Sex Offender Civil Commitment: Science and the Law (online here)

The photo of the DSM manuals is from the Bonkers Institute for Nearly Genuine Research, a very creative website.

Fed court OK's unorthodox diagnoses for sex offenders

Last September, I posted about two legal challenges to the use of controversial psychiatric diagnoses to justify the civil commitment of sex offenders.

The US District Court for the Eastern District of Wisconsin has since issued final opinions on both challenges, allowing the use of the diagnoses of "Paraphilia Not Otherwise Specified-Nonconsent" and "Personality Disorder Not Otherwise Specified with Antisocial Features." Neither diagnosis is included in the psychiatric bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), nor are they commonly invoked in mainstream psychology or psychiatry. In the DSM, "NOS" is a residual category used when someone does not meet all criteria for a listed disorder; many clinicians refer to it as a "garbage diagnosis." (For a facetious take on the NOS label, see this essay.)

The twin rulings, against sex offenders Bruce Brown and Michael McGee, echo similar rulings in other states that make it easier for the government to get sex offenders involuntarily hospitalized after they finish serving their prison terms. To be Constitutional, according to the U.S. Supreme Court, such civil commitment based on a likelihood of future sex offending must be linked to a "mental disorder" or "mental abnormality." This is where psychologists and psychiatrists come in, and the industry has become a lucrative cash cow for some evaluators.

"Paraphilia Not Otherwise Specified-Nonconsent"

The tone of Judge Lynn Adelman's decision in the case of Brown v. Watters was a turnaround from his earlier ruling in the same case, in which he had sent the case back to the state court for additional proceedings. At that time, last July, he expressed doubts about use of the diagnosis of Paraphilia NOS-Nonconsent to justify civil commitment, saying it might be too broad to pass Constitutional muster: "[I]t may be that every criminal convicted of a sexual crime could be diagnosed with the disorder."

As the judge noted, a paraphilia is defined in the DSM as a chronic pattern of intense, sexually arousing fantasies, sexual urges, or behaviors generally involving nonhuman objects, suffering or humiliation, or children or other nonconsenting persons.

Rape is not included as one of the paraphilias in the DSM, and use of the residual category of "Not Otherwise Specified" for this legal purpose is controversial.

As of this writing, Brown's case is on appeal to the U.S. Court of Appeals for the 7th Circuit.

"Personality Disorder Not Otherwise Specified with Antisocial Features"

In a related case brought by sex offender Michael McGee, the same court also upheld the use of the diagnosis "Personality Disorder Not Otherwise Specified with Antisocial Features" as a basis for civil commitment.

The parallel opinions interpret the landmark U.S. Supreme Court case of Kansas v. Crane as allowing such unorthodox diagnoses in the service of "practicality." The Crane case, said the opinion in McGee v. Bartow, "made clear that courts should be driven more by practical considerations than the technical distinctions underlying much of psychiatry." The government "has wide latitude in defining a term like 'mental illness' or 'mental abnormality,' " echoed the ruling in Brown v. Watters, and need not limit itself to diagnoses that are "generally recognized in the medical community."

In other words, so long as experts testify that a sex offender has a disorder that causes him to have serious difficulty controlling his sexually violent behavior, the offender's Constitutional right to due process is satisfied.

Evaluator disputes characterization

Meanwhile, Dennis Doren, a prominent sex offender evaluator who testified in the Brown case, has issued a written statement in response to the Brown v. Watters opinion and my blog post last September reporting on the ruling.

In his statement, "Setting the Record Straight," Doren said the court was mistaken in claiming that he testified that he had created the diagnosis of Paraphilia NOS-Nonconsent. Rather, he wrote, he simply changed the extant phraseology from Paraphilia NOS-Rape (a more legal term) to Paraphilia NOS-Nonconsent (a more medical term), while creating a list of diagnostic indicators which he published in a manual for sex offender evaluators.

It is certainly true that Doren did not invent the concept of a preferential desire to rape, which has been recognized for a long time and has been called everything from bioastophilia to rapism. But most observers agree that Doren's manual did popularize and legitimize use of the "NOS" diagnosis in the sex offender civil commitment industry.

Doren said he made his recommendations not only to "bridge the gap or defiiciency of the DSM-IV" but also out of concern that evaluators were overdiagnosing Paraphilia NOS based simply on behavior, without regard to the requirement that the offender demonstrate a preference for forcible sex.

This type of overdiagnosis in the pursuit of civil commitment is a valid concern. Research suggests that only a small percentage of rapists are motivated by a preferential sexual attraction to rape. And offenders who are mislabeled face the daunting prospect of lifelong hospitalization without the due-process protections afforded by the criminal justice system.

These controversial diagnostic issues in civil commitment proceedings may finally be about to get some much-needed scrutiny and debate. The editor of the DSM-IV-TR, Michael First, has two articles in press taking issue with the way the DSM paraphilia diagnosis has been interpreted in civil commitment proceedings. His forthcoming editorial in the American Journal of Psychiatry is entitled "Issues for DSM-V; Unintended Consequences of Small Changes: The Case of Paraphilias." A lengthier analysis in the Journal of American Academy of Psychiatry and the Law is entitled "Use of DSM Paraphilia Diagnoses in Sexually Violent Predator Commitment Cases." Meanwhile, Doren's essay, "Setting the Record Straight," has also been accepted for publication, in Sex Offender Law Report.

Hat tip to Susan Sachsenmaier for alerting me to the Wisconsin case developments

Psychiatry rejects new rape disorder for DSM-5

Regular blog readers will be familiar with the heated battle over a controversial proposed mental condition of "Paraphilic Coercive Disorder" for rapists. Now, the American Psychiatric Association has issued its latest draft of the DSM-5 diagnostic manual, with the condition relegated to the appendix. The proposal was favored by psychologists working for the government in Sexually Violent Predator (SVP) civil commitment cases, as it would have made it far easier to testify that sex offenders are mentally ill. It had met with strong opposition from scientists, including premier rape researcher Raymond Knight of Brandeis University.

Among other outspoken opponents was psychiatrist Allen Frances, an emeritus professor from Duke University who chaired the DSM-IV Task Force. In blog posts soon to go live at the Psychiatric Times and Psychology Today, he cautions that the battle is not over: The current attempt to place the pseudoscientific condition into the appendix of the DSM 5 as a condition warranting further study is still a mistake.

"Important message"

Dr. Frances said the rejection should send a strong message to those involved in the SVP civil commitment industry:

Dr. Allen Frances

The evaluators, prosecutors, public defenders, judges, and juries must all recognize that the act of being a rapist almost always is an indication of criminality, not of mental disorder. This now makes four DSM's (DSM III, DSM IIIR, DSM IV, DSM 5) that have unanimously rejected the concept that rape is a mental illness. Rapists need to receive longer prison sentences, not psychiatric hospitalizations that are constitutionally quite questionable.

This DSM 5 rejection has huge consequences both for forensic psychiatry and for the legal system. If "coercive paraphilia" had been included as a mental disorder in DSM 5, rapists would be routinely subject to involuntary psychiatric commitment once their prison sentence had been completed. While such continued psychiatric incarceration makes sense from a public safety standpoint, misusing psychiatric diagnosis has grave risks that greatly outweigh the gain…. Preventive psychiatric detention is a slippery slope with possibly disastrous future consequences for both psychiatry and the law. If we ignore the civil rights of rapists today, we risk someday following the lead of other countries in abusing psychiatric commitment to punish political dissent and suppress individual difference.

This DSM 5 rejection of rape as mental disorder will hopefully call attention to, and further undercut, the widespread misuse in SVP hearings of the fake diagnosis "Paraphilia Not Otherwise Specified, nonconsent". Mental health evaluators working for the state have badly misread the DSM definition of Paraphilia and have misapplied it to rapists to facilitate their psychiatric incarceration. They have disregarded the fact that we deliberately excluded rape as an example of Paraphilia NOS in order to avoid such backdoor misuse. Not Otherwise Specified diagnoses are included in DSM only for clinical convenience and are inherently too idiosyncratic and unreliable to be used in consequential forensic proceedings.

Exclude coercive paraphilia from appendix

All along, promoters of this new diagnosis have conceded that this would be a tough sell, given its lack of scientific foundation. Indeed, they said publicly that they would consider it a victory if they could even get paraphilic coercive disorder included in the appendix of the upcoming diagnostic manual (due out in mid-2013), as a condition meriting further study. But as Dr. Frances points out, even that would be a major error:

The sexual disorders work group proposes placing "coercive paraphilia" in an appendix for disorders requiring further research. We created such an appendix for DSM IV. It was meant as a placement for proposed new mental disorders that were clearly not suitable for inclusion in the official body of the manual, but might nonetheless be of some interest to clinicians and researchers….

If "Coercive Paraphilia" were like the average rejected DSM suggestion, it would similarly make sense to park it in the appendix -- as has been suggested by the DSM 5 sexual disorders work group. This might facilitate the work of researchers and also provide some guidance to clinicians....

But "coercive paraphilia" is not the average rejected DSM diagnosis. It has been, and is continuing to be, badly misused to facilitate what amounts to an unconstitutional abuse of psychiatry. Whether naively or purposefully, many SVP evaluators continue to widely misapply the concept that rape signifies mental disorder and to inappropriately use NOS categories where they do not belong in forensic hearings.

Including "Coercive Paraphilia" in the DSM 5 appendix might confer some unintended and undeserved back-door legal legitimacy on a disavowed psychiatric construct. Little would be gained by such inclusion and the risks of promoting continued sloppy psychiatric diagnosis and questionable legal proceedings are simply not worth taking. The rejection of rape as grounds for mental disorder must be unequivocal in order to eliminate any possible ambiguity and harmful confusion. We did not include any reference to "coercive paraphilia" in DSM IV and it should not find its way in any form, however humble and unofficial, into DSM 5. 

If you agree that this pseudoscientific condition needs to be placed in the wastebasket once and for all, now is the time to speak up. The current public comment period ends June 15. While you’re at it, you might want to state your opposition to a couple of the other controversial proposals with potential for profound negative consequences in the forensic realm – pedohebephilia and hypersexuality.

Postscript: Thanks to the suggestion of an alert reader, I have added the direct links to the DSM-5 comments pages. You must register in order to submit a comment.

• Click HERE to comment on the proposed diagnosis of Pedohebephilia.
• Click HERE to comment on the proposed diagnosis of Paraphillic Coercive Disorder.

Related posts:

• Psychiatrists ramp up opposition to forensic misuse of DSM: "Pedohebephilia" would make bad situation worse, they warn (March 10, 2011)
• Europeans first to shoot down controversial paraphilia (Oct 26, 2010)
• Psychiatrists vote no on controversial paraphilias (Oct. 24, 2010)
• Rape as psychiatric illness: Battle heats up (June 24, 2010)
• Latest hebephilia critiques: Point-counterpoint (March 12, 2010)
• More prominent voices join chorus of DSM-5 critics (March 1, 2010)
• DSM-V: Will shoddy manual implode years before launch date? (Feb. 20, 2010)
• New Scientist expose of psychiatry’s "civil war" (Dec. 10, 2009)
• Scientist razes proposed "Paraphilic Coercive Disorder" (Nov. 6, 2009)
• Hebephilia struck by third blow: Down but not out? (June 5, 2009)
• Wrangling over psychiatry's bible (Nov 16, 2008)
• DSM makeover: What will they come up with next? (Oct 13, 2008)
• Invasion of the hebephile hunters (Oct 31, 2007)

Asperger’s: Here today, gone tomorrow?

Would erasure from DSM impact forensic use?

It was just a few years ago that Asperger's Disorder exploded into the public consciousness. But just as suddenly, if the DSM-V authors have their way, it may disappear, absorbed back into the spectrum of autism disorders from whence it came.

An intriguing story in today's New York Times describes the controversy that is heating up as the DSM-V work groups prepare to issue their final diagnostic proposals in January.

As Times reporter Claudia Wallis notes, Asperger's is "one of the most intriguing labels" in the diagnostic book:

"Children with Asperger's syndrome, a mild form of autism, are socially awkward and often physically clumsy, but many are verbal prodigies, speaking in complex sentences at early ages, reading newspapers fluently by age 5 or 6 and acquiring expertise in some preferred topic -- stegosaurs, clipper ships, Interstate highways -- that will astonish adults and bore their playmates to tears."

The sudden rise of this "once obscure diagnosis," diagnosed four times more often in boys than girls, accounts for much of the apparent rise in autism, which now has a prevalence rate of about 1 percent among U.S. children.

Although self-described "Aspies" and their families distinguish Asperger's from the more stigmatized label of autism, experts quoted by the Times say the distinctions are confusing and not scientifically based.

Asperger's in the forensic context

At the same time that it faces formal extinction, Asperger's is seeing ever-escalating use in the criminal courts, in cases ranging from violent crime to computer hacking and child pornography possession.

Typically, the diagnosis is proposed by defense attorneys seeking to mitigate the mental state required for a crime. A hallmark of the disorder is severe problems understanding social rules and nuances, and therefore navigating social situations. Sometimes, the profound deficit in social reasoning explains crimes that otherwise are simply bizarre, and lacking in rational motivation. Consider this scenario, adopted from a case I worked on:

You’re on an excursion with a recreational group, walking through a downtown area. The group encounters a red light. Seeing no traffic, everyone jaywalks. All except the young man with Asperger’s, whose can’t break a rule. No one notices as he gets left behind. When he finally finds the group again, he is furious, and punches the group leader in the face.

In this case, the defendant had a particularly severe and clearcut case that had been diagnosed and treated at a specialty clinic from the time he was a toddler. Thus, it could not be argued that the diagnosis was being manufactured with a pretextual goal in the legal context.

In other cases, especially when an alternate and rational motivation is at least equally plausible, the defense has met with less success. For example, as I blogged about last year, it was unsuccessfully advanced in the case of Hans Reiser, the oddball computer programmer who killed his wife and buried her body in the hills of Oakland, California.

In an article on "the geek defense" in Slate magazine, science writer Erica Westly gives other examples of Asperger's recent deployment in court, some successful and some not.

• Astonishingly, a jury in Galveston, Texas acquitted billionaire real estate heir Robert Durst in the murder and dismemberment of his neighbor under the theory that Asperger's made him incapable of premeditating the crime.

• Lisa Brown of the United Kingdom was not so lucky. The 22-year-old woman was sentenced to life in prison in the murder of her mother after a judge ruled that her lack of empathy did not mitigate the gravity of the crime.

Explanation for collecting child porn

The compulsive behaviors and zealous collecting of many individuals with Asperger's is being invoked to explain certain types of criminal conduct, such as computer misconduct or child pornography collecting.

Computer hacker Gary McKinnon

The Slate article features the high-profile case of Gary McKinnon, the British computer geek who hacked into U.S. military and NASA computers looking for proof that the U.S. government had covered up evidence of UFO landings. He claims Asperger's made him compulsively driven to search for evidence of alien spacecraft.

This type of defense is ready-made for compulsive collecting of child pornography images. In an Iowa case this year, a judge reduced a pornography possession sentence after concluding that Asperger's "might very well explain the number of images" the man had acquired. Similarly, across the Atlantic a 21-year-old student in the United Kingdom was sentenced to just four months in jail for possession of 922 pornographic images of children. Other courts have been less sympathetic to this version of a diminished capacity defense.

Anecdotally, I have heard of Asperger's arguments backfiring. Introduced as mitigation in cases of violent and/or sexual offending, Asperger's may become aggravating by increasing jurors' fear of a defendant because he is perceived as strange and therefore more unpredictable.

At risk in prison

In a final forensic angle, the extreme social awkwardness of Asperger's sufferers puts them at risk in prison, where social interactions are highly scripted and regulated. In one case I was involved in, a prisoner incurred new criminal charges stemming from a bizarre fight triggered by his misperception of social cues.

Indeed, computer hacker McKinnon is raising this issue in an attempt to avoid extradition to the United States. Given his condition, incarceration in a U.S. prison would amount to torture, he contends. As evidence, he cites a 2007 study by psychiatrist David Allen finding that imprisonment is extremely stressful and confusing for men with Asperger's, who find it hard to successfully interact with guards and other prisoners and thus spend much of their time hiding out in fear.

No one knows whether or how exclusion from the upcoming DSM-V, due to be published in 2012, might affect deployment of the diagnosis in court. After all, even if it is not a separate diagnosis, Asperger's will still presumably exist as a condition on the autism spectrum. And, as regular readers of this blog know, plenty of less valid diagnoses are invoked in court despite their absence from the DSM.

Although I understand the logic of the DSM-V work group, I cannot help but wonder -- given the massive influence of the pharmaceutical industry in shaping and perpetuating psychiatric diagnoses -- whether they would be proposing Asperger's for elimination if a money-making drug was available to treat it.

Somehow, I think not.

Further resource:

Barry-Walsh, J.B., & Mullen, P.E. (2004). Forensic aspects of Asperger's Syndrome. Journal of Forensic Psychiatry and Psychology, 15, 96-107.

New Scientist expose of psychiatry’s "civil war"

Proposed diagnoses of hebephilia and paraphilias NOS critiqued

On Saturday, the world's leading science and technology news weekly is publishing a scathing expose of the political and financial shenanigans underlying the DSM-V revision process. Accompanying the report in the New Scientist is an editorial calling for a halt to the print version of the American Psychiatric Association's money-making diagnostic bible:

The final wording of the new manual will have worldwide significance. DSM is considered the bible of psychiatry, and if the APA broadens the diagnostic criteria for conditions such as schizophrenia and depression, millions more people could be placed on powerful drugs, some of which have serious side effects. Similarly, newly defined mental illnesses that deem certain individuals a danger to society could be used to justify locking these people up for life.

Given such high stakes, we should all be worried by the controversy. Proponents of some of the changes are being accused of running ahead of the science, and there are warnings that the APA is risking "disastrous unintended consequences" if it goes ahead with plans to publish DSM-V, as the new manual will be known, in 2012.

"Psychiatry’s civil war" is the title of the hard-hitting expose by award-winning science writer Peter Aldhous, San Francisco bureau chief for New Scientist magazine.

As Aldhous reports, professional disputes over the form and content of the upcoming edition "are getting ugly." He notes that respected Duke University scholar Jane Costello has resigned from the work group on childhood and adolescence disorders, citing a lack of scientific rigor across the whole DSM revision. "I felt that there was not enough empirical work being achieved or planned," she says.

In a sidebar, Aldhous shines a spotlight on controversial proposals of pivotal importance to forensic psychology, including the pseudoscientific diagnosis of "hebephilia" that I have previously blogged about:

You may have never heard of "hebephilia", but this obscure diagnosis has huge significance in the courts. If it becomes accepted it could lead to hundreds of sex offenders who have served their jail time being locked up indefinitely - on grounds that some say are spurious.

The proposed diagnosis has been condemned by critics as dangerously blurring the boundary between paedophilia and normal male attraction to teenage girls -- which isn't necessarily acted upon. Karen Franklin, a forensic psychologist in El Cerrito, California, argues that the diagnosis makes a disease out of preferences that have been shaped through human evolution. "People didn't used to live so long and mating started earlier," she says.

The work group is also considering whether some men are specifically turned on by rape -- a proposed condition termed paraphilic coercive disorder. Again, the evidence is based largely on measurements of penile blood flow in response to sexual images and stories, and the validity of the condition is hotly contested.

The rows over hebephilia and paraphilic coercive disorder aren't academic, because 20 US states have passed laws that allow sex offenders who have served their sentences to be detained indefinitely in a secure hospital if they are deemed "sexual predators." This can only be done if the offenders have a psychiatric disorder that increases their risk of reoffending -- which few do, according to DSM-IV.

Franklin says that if hebephilia and paraphilic coercive disorder make it into DSM-V, they will be seized upon to consign men to a lifetime of incarceration.

In a call to put the brakes on this speeding train, the New Scientist's accompanying editorial points out that this would hurt the coffers of the American Psychiatric Association, which has earned more than $40 million since 2000 from DSM sales. But, the editorial concludes, "it's hard to see who else stands to gain from the current exercise -- and if the critics' dire predictions come to pass, patients will be the biggest losers."